ANNALS OF SURGERY Vol. 188

September 1978

No. 3

Presidential Address Alfred Blalock DAVID C. SABISTON, JR., M.D.

IT IS A GREAT PRIVILEGE to express my appreciation for the honor of serving as President of the American Surgical Association, and to all my friends and colleagues let me say that I am humbly thankful for your confidence. During the past year I have thought repeatedly of my good fortune in being given this privilege, and I shall remain ever grateful for your gracious kindness. I believe it is useful to pause from time to time to examine closely the profile of those who have had a great impact upon us, especially those giants who have established standards for the leaders and contributors of tomorrow. Such figures have established careers which serve as goals for the industrious and committed young men and women, not only to meet, but indeed to exceed. As I reflect upon my own educational experience and the many teachers whom I have admired, there is one far more than any other who remains foremost. His breadth of vision, his concepts of teaching, his approach to clinical surgery, his emphasis upon original investigation, and his recognition of the importance of effective administration have remained since my first encounter with him as a second year medical student. With the passage of time, his shadow continues to lengthen, and a day seldom passes but that my thoughts return to him, usually with the simple question, "How would he have managed this?" In reviewing the career of Alfred Blalock, I hope

From the Department of Surgery, Duke University Medical Center, Durham, North Carolina

Presented at the Annual Meeting of the American Surgical Association, April 24-29, 1978, Dallas, Texas.

that his profile will especially interest the younger members and cause them to reflect upon his careful planning of an outstanding career. Of equal importance is a clear recognition of the pleasure he obtained throughout his life, especially in his unique ability to help others. As one assesses his career and his achievements, it becomes indelibly clear that the entire span was carefully planned from the outset, and that he achieved in a stepwise and ever widening manner those goals which he had established many years earlier. There is much to be learned from great men not only from a philosophic point of view, but more important from the practical aspects of those issues and problems of daily life. A glimpse of his early life, education, and training provides much insight into the remarkable contributions which were to follow. We learn from his cousin J. Dorsey Blalock that the first of the family to arrive from England was Patrick Blalock, whose name is listed in a colonial grant and who settled in Virginia in 1620. Further investigation shows that a number of his forebears served in the Revolution and in the War Between the States, and in Georgia the name of Blalock is well known in a variety of endeavors including law, business, agriculture, politics, and many other fields. Alfred Blalock was born on April 5, 1899, in Culloden, a small town in mid-Georgia. His father owned a large cotton plantation and was a well known merchant. Alfred was the oldest of five children and commented from time to time that his father was a strict

0003-4932/78/0900/0255 $01.25 C J. B. Lippincott Company

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SABISTON

Ann.

Surg. e September

1978

Alfred Blalock

disciplinarian.. It is fortunate today that at one point he was asked to prepare a short biographical sketch of himself, and the insights obtained from reviewing it are penetrating. Of his early life, he said, "I had a very pleasant environment at home. . . . My father encouraged us to read worthwhile books . . . and he would help me with my studies." He attended the public schools in Culloden and then attended Georgia Military College, an academy recognized as being a preparatory school for the University of Georgia. As a result of academic success there, he was admitted to the University of Georgia as a sophomore in the fall of 1915, and of that time he was later to say, "My favorite study in college was zoology. Languages were fairly easy for me, but such was not the case with mathematics and

physics." He continues his description of that period by saying: I received my Bachelor of Arts Degree at the University of Georgia in the spring of 1918, shortly having passed my nineteenth birthday. I had known for some several years that I wished to study medicine, and it was largely through the efforts of Dr. Campbell, Professor of Zoology, that I was accepted

for admission to the Johns Hopkins School of Medicine. While in medical school at Hopkins, his best work was in the surgical courses. For example, in his senior year, one finds in the class roll in the archives of the Welch Medical Library that he was awarded a grade of 9 out of a possible 10 as the final mark in

Vol. 188 . No. 3

PRESIDENTIAL ADDRESS

the course. In fact, only four students of the 80 in the class outranked him. It is also interesting to note the number of outstanding students in the class of 1922, names later to become known for a wide variety of important contributions, including those of Arthur Blakemore, Robert Elman, Tinsley Harrison, Chester Scott Keefer, Orthello Langworthy, and many others. One of the most interesting letters to be found in the Blalock papers is one which he wrote to Dr. Halsted, while a senior medical student, in December 1921. It is interesting to note the similarity of his handwriting at that time with that which continued years later. In addition, his choice of words and expressions, even at that time, are characteristic and were often repeated in succeeding years (Fig. 1). Dear Dr. Halsted-, The writer of this letter is a member of the present fourth year class and it concerns an appointment in surgery for next year. I would like very much to have the place in experimental surgery. My only work in this department has been in the third year elective course and a little work in which I assisted Dr. McLean. Despite the fact that I know little of the work I feel very interested in it and would like an opportunity to try it. If I should get an appointment and make good, I hope to work in a surgical clinic for a number of years, as I have no immediate desire to start practicing. During my three years as a medical student, I have worked seven months in the summers in surgery, and I feel absolutely sure that I want to follow it. The past summer I substituted two months here in general surgery and I enjoyed it very much. As the greatest number of my patients were Dr. Dandy's, I think he could best give you an idea.as to my work. If my name is considered for the place, I would appreciate a personal interview. At any rate, I shall put in my application. Yours sincerely, Alfred Blalock 518 North Broadway Baltimore, Maryland From this letter, it is apparent today that one can almost chart the course of Dr. Blalock's life since the code is clearly contained within it. It is interesting to note the attention which Dr. Halsted gave to detail since, despite his duties as a busy and involved director of a department, he replied to this letter stating: Dear Mr. Blalock: I am pleased to receive your letter of the first inst. and to know that you are an applicant for a

257

position in the Hunterian Laboratory. These positions will be reserved for men of high standing in the class, and I shall have to investigate your records before giving you a definite answer.

Very truly yours, William S. Halsted It is generally believed that Alfred Blalock was later greatly disappointed that he did not obtain one of the appointments for a position in Dr. Halsted's famed residency program. Nevertheless, it is a matter of record that he was always quite candid about the fact that he was not chosen to remain for the full program, and in his files are several references on this point. He once stated, "Following one year as an assistant resident on the surgical service, the competition became too keen and I sought a position elsewhere without success." He then turned to Dr. Samuel R. Crowe, Professor and Head of the Division of Otolaryngology, for assistance, and a letter to Dr. Harvey Cushing was forthcoming. Dr. Blalock continued, "Following Dr. Crowe's letter, I was offered a position at the Peter Bent Brigham Hospital under Dr. Cushing but later decided to go to Vanderbilt with Dr. Barney Brooks, who had been recommended to me by Dr. Halsted. After two years at Vanderbilt I became ill and had to go to the Adirondacks." As many know the attack of pulmonary tuberculosis and his confinement at Trudeau Sanatarium was a very depressing experience. A small area of increased density of the left apex with mottling and scarring was noted in the chest film, and his sputum was positive for acid-fast organisms. After a year there he wrote: I requested that I be given pneumothorax treatments, but they refused. I then decided to go to Europe . . . and on a visit to Berlin I became rather ill and sought the advice of Dr. Sauerbruch. He treated me rather miserably. Finally, he advised me to have a thoracoplasty, but I refused and returned to Saranac Lake.

Following the pneumothorax treatments, he returned to Nashville, but despite the fact that he remained under intensive treatment with pneumothorax for two years, he worked continuously and was known to have missed only one or two days' work during the entire time. This is a clear example of his perseverance, of his industry, and of his tenacity, each feature that was to characterize him throughout the remainder of

his life. Dr. Blalock's first paper was published while a resident in Baltimore and concerned a clinical study of biliary tract disease in which he reviewed 735 pa-

258

SABISTON

tients with this disorder and was published in the JAMA in 1924 (Fig. 2). The fact that it was a clinical paper is significant in that, despite his unconcealed love for the experimental laboratory, he always insisted that there be clear clinical implications in laboratory investigation. The first experimental paper appeared in The Journal of Clinical Investigation in 1925 and concerned the effects of changes in hydrogen ion concentration on the blood flow of morphinized dogs. It is interesting that at such an early date he and his colleagues employed exacting techniques for determination of pH with accuracies of 0.03, and performed concomitantly with determination of the amount of oxygen consumed and carbon dioxide released by the lungs. His early work with Tinsley Harrison on circulatory problems led quite naturally to his becoming involved in studies relating to the pathogenesis of shock. He often referred to this period of his life and placed great emphasis upon spending considerable time in the experimental laboratory during the course of surgical training. He recognized clearly the importance of this phase of academic development, and this philosophy is reflected in his many hours of dedicated work in the laboratory. Of particular significance in the development of his scientific career was the time spent in England at the Physiological Laboratories in Cambridge. In 1927 he worked in Adrian's Laboratory and while there was introduced to painstaking and rigid physiological techniques. He referred to this period in later life recalling that it was in that laboratory he first learned the importance of meticulous attention to detail, particularly in the conduct and interpretation of experimental work. While in Cambridge, his work was on the subject of blood flow in skeletal muscle assessed by the anemometer. The principle involved was the employment of hot wire in the form of a spiral of platinum about 12 microns in diameter and mounted in a metal cylinder, a very involved technique for surgical investigators in that early day. The work entitled "Observations upon the Blood Flow through Skeletal Muscle by the Use of the Hot Wire Anemometer" was published in The American Journal ofPhysiology. Another paper from that laboratory concerned the distribution of blood flow in the coronary circulation, and these studies represented his first work in cardiac physiology. It was entitled "The Distribution of the Blood in the Coronary Blood Vessels" and was published in the British Journal of Physiology in 1929. This experience at Cambridge, with a group of such distinguished physiologists, provided a rigorous standard in the collection of experimental data which was to remain with him always. In 1928, Dr. Blalock returned to Vanderbilt with a firm understanding of basic physiological principles and having mastered a number of important investigative

Ann. Surg. * September 1978

techniques. These were rapidly put to work in the Surgical Research Laboratory in Nashville, and 1928 to 1941 was probably the most productive time of his life. Thus, he was to subsequently say, "My research problem was that of traumatic shock and my main clinical interest was thoracic surgery." During that period, the status of shock was in a state of total disarray with many conflicting views concerning its pathogenesis. As was characteristic of all his undertakings, he insisted that simple questions be answered first and therefore designed an experiment which was to remain a classic. In an anesthetized animal, the thigh was injured by blunt trauma and some hours later its weight was compared with that of the control limb following exacting dissection. In the traumatized limb, the increased weight was shown to account for 66% of the circulating blood volume, thus explaining the loss of intravascular volume into the tissues and accounting for the hypotensive state. In this simple, but brilliant, experiment, he was able to show that shock is due primarily to the loss of circulating blood and plasma from the vascular compartment, either externally or into the tissues (Fig. 3). These early studies were noted widely, and at the young age of 34 he was elected a member of the American Surgical Association. In 1933 he was invited to give the Arthur Dean Bevan Lecture in Chicago, almost certainly the youngest ever to deliver this distinguished lectureship. He reviewed his important contributions under the title of "Acute Circulatory Failure as Exemplified by Shock and Haemorrhage" (Fig. 4). It is of considerable significance that such an authority as Sir George Pickering, the Regius Professor of Medicine at Oxford, was to refer to this work saying: "The conclusion that emerged from World War I was that shock was a traumatic toxemia produced by the effects of vasoactive substances like histamine from injured muscles. It needed the genius of your Alfred Blalock and the experience of the second World War to show that this was not so." His work on experimental and clinical shock was summarized in a well known monograph entitled "Principles of Surgical Care, Shock and Other Problems," and his warm interest in people and his appreciation of their assistance were typified when he said in the introduction: "My excellent technician, Vivien Thomas, has been responsible for the execution of many of the experiments." Dr. Blalock spent many hours with him and he became an outstanding assistant who was to have a major role in subsequent years. While in Nashville, Dr. Blalock met and married Mary O'Brien, a Nashville belle who was known for her charm and beauty, and the wedding was widely reported in the newspapers of the day. All their friends recognized the great support which she pro-

Vol. 188 . No. 3

259

PRESIDENTIAL ADDRESS

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FIG. 1. Letter written by Alfred Blalock to Dr. William S. Halsed o Deembe 1,1921.

A CLINICAL STUDY OF BILIARY TRACT DISEASE * ALFRED BLALOCK, M.D. BALTIMORE

This paper is based on a statistical study' of all cases with a diagnosis of disease of the biliary tract that have been in the surgical service of the Johns Hopkins Hospital between 1889 and 1924. This consideration will not ihclude the cases with malignancy of the biliary tract, and those with a clinical FIG. 2. Title page of Alfred Blalock's first paper published in the JAMA, 83: 2057, 1924.

FIG. 3. Diagrammatic illustration of technique employed by Alfred Blalock in demonstrating the pathogenesis of traumatic shock.

260

SABISTON

vided him and their three fine children, Bill, Betty, and Dandy Blalock. It was also at Vanderbilt that Dr. Blalock's pioneering work on myasthenia gravis and its relationship with the thymus was done. Of this period he was to say: "I remained at Vanderbilt for 16 years advancing from Instructor in Surgery to full Professor in the Department directed by Dr. Brooks." It is appropriate to emphasize that he had already made a number of important scientific contributions and was clearly a national figure. He was respected not only by clinical surgeons but by physiologists, biochemists, and others in basic science alike. In subsequent years, his general insistence upon having achieved a rather solid scientific background before assuming major administrative duties was a principle that he frequently emphasized. Certainly it was clear in his situation that the strong background teaching at Vanderbilt, the fact that he was a pioneer in clinical thoracic surgery, particularly in diseases of the thymus and pericardium, and his brilliant research combined to make him an ideal choice for a prominent chair in surgery. In 1940, there was considerable controversy in Baltimore concerning the choice of a successor to Dr. Dean Lewis as Professor of Surgery at Johns Hopkins. The first letter in the Blalock files referring to this issue is one from his close friend Samuel Crowe who wrote: Dear Al: Thank you for sending me a copy of your book. I am just leaving for a few weeks' rest in some cool spot and will there read your book with a great deal of interest and pride. We need you here and I wish I had the authority to make the appointment. As ever yours, Samuel J. Crowe The Surgical Search Committee recommended as its first choice a former resident of Halsted, Dr. Mont Reid, Professor of Surgery at the University of Cincinnati. However, he chose to remain in Cincinnati, and Evarts A. Graham was next offered the post. In declining the position, he took the opportunity to recommend to President Bowman the name of Alfred Blalock. During a visit shortly thereafter, it became obvious that President Bowman was greatly impressed by the 41-year-old Blalock and was quite influential in the Committee's decision to make him the offer, an offer which was accepted. Following the announcement in The Baltimore Sun (Fig. 5), there were many letters of congratulation and portions of some of them follow. From the late Edward D. Churchill came the following: Believe me when I say that our backing will not end with the appointment but that you may feel free

Ann.

Surg. * September 1978

to call upon me for anything that I can do to help in the problems that lie ahead. You are the only man for the job, and that has been apparent to everyone outside of Baltimore from the very start and now that they have seen the light, let's make a go of it. Affectionately and loyally, Pete Churchill

The Mayo Clinic's Donald Balfour was to say: No greater honor could come to anyone and I know the entire surgical profession is elated that you have accepted. I want to express my own good wishes and my conviction that you will maintain the high standards of Hopkins. From the Peter Bent Brigham came Elliot Cutler's letter: "It is simply wonderful for everybody, an Al for Hopkins, a splendid opportunity for you, and a well deserved one. " One of Halsted's former residents, George Heuer, Professor of Surgery at Cornell, was to write: "From all I can gather, there is a great job to be done down there and I believe you are the fellow who can do it." Lester Dragstedt wrote from Chicago, "We are confident that you will be a worthy successor to the great Dr. Halsted and continue the fine work that he so ably began." Frederick Coller wrote from Ann Arbor: "There is no one in the country who will grace it better, and I am sure that in no place in the country is your work more admired and you yourself better liked than in Michigan." From Warren Cole came: Dear Al: I was expecting to see you in Washington and to congratulate you upon your appointment at Hopkins, but you were presumably unable to attend. In reality, however, I wish to congratulate Hopkins in obtaining the right and best man for the job. I want to extend to you my sincere wishes for many happy years there in Baltimore. And the Professor of Medicine and Director of the Department at Hopkins, the distinguished Warfield T. Longcope, was to say: "There is much to be done, as you probably know, but you will find an active and interested group who will be ready to cooperate in every way that they can." His close friend Samuel Crowe, the Chief of the Division of Otolaryngology, wrote: I am very tardy in writing and telling you how happy I am that you are coming to Baltimore. You have a great opportunity here. The Surgical Department has been drifting downstream since the death of Dr. Halsted in 1922. You may count on me to do

VOl. 188 . NO. 3

PRESIDENTIAL ADDRESS

261

ACUTE CIRCULATORY FAILURE AS EXEMPLIFIED BY SHOCK AND HkEMORRHAGE ' ALFRED BLALOCK, M.D., NASHVILLE, TENNESSEE From the Department of Surgery of Vandabilt University

HE title of this lecture is "Acute Circulatory Failure As Exemplified By Shock and Haemorrhage." It seems appropriate that this subject should have been chosen since such noteworthy contributions concerning the etiology of shock have been made by one of Dr. Bevan's former associates, Dr. D. B. Phemister. Various terms have been used to designate the condition which follows severe injury. These include traumatic torpor, stupor, prostration without reaction, syncope, collapse, neuroparalysis, Wundschreck, Erschuetterung,irritationwithout reaction, exaemia, depressant syndrome, traumatic toxemia, and traumatic hypodromia. The term that has been almost universally adopted is "shock." According to Groenin-

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FIG. 4. Title page of the Arthur Dean Bevan Lecture delivered in Chicago, October 20, 1933, and published in Surgery, Gynecology & Obstetrics, 58: 551, 1934.

the floor, he makes no effort to move or look about him. He lies staring at the surgeon with an expression of complete indifference as to his condition. There is no movement of the musdces of the face; the eyes, which are deep sunken in their sockets, have a weird, uncanny look. The features are pinched and the face shrunken. A cold, clammy sweat exudes from the pores of the skin, which has an appearance of profound anemia. The lips are bloodless and the fingers and nails are blue. The pulse is almost imperceptible; a weak, thread-lke stream may, however, be detected in the radial artery. The thermometer placed in the rectum registers 96 or 97 degrees F. The muscles are not paralyzed anywhere, but the patient seems disinclined to make any muscular effort. Even respiratory movements seem for the time to be reduced to a minimum. Occasionally the patient may throw about one -of his limbs and give vent to a hoarse weak groan. There is no insensibility but he is strangely apathetic, and of seems to realize but imDerfectlv the fOll m on

Appointed *Hopkins Surgery Chief, Succeedinq Dean Lewi

Dr. Blalock

Professor At Vanderbit tinlversity Gets ChaiIn Medcai School

Unanimous SleIe ct Comes After Nation-Wide Hunt For Man For Post D,

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FIG. 5. Announcement in The Baltimore Sun of the appointment of Alfred Blalock as Professor of Surgery and Director of the Department of Surgery of the Johns Hopkins University School of Medicine and Surgeon-in-Chief of the Johns Hopkins Hospital.

FIG. 6. Photograph of Dr. Blalock's famous Friday Noon Clinic. The surgical residents are sitting on the front rows and a senior medical student is presenting a patient to Dr. Blalock who is standing next to the child's bed.

SABISTON

262

everything in my power to aid you. Thirs will indeed be a new year for the Medical School andI University. Throughout Dr. Blalock's career, his (close friendship with basic scientists is a frequent1ly recurring feature. Moreover, he received many laud from them, which was again true on his aplpointment at Hopkins. Thus, from Irvine Page came thie following: Dear Alfred: I can't tell you how delighted I wa:s to read of your appointment to the Professorship at Hopkins. We all know you richly deserve it andi in thinking it over, I am convinced that there is no one that I personally would have wanted more tthan you.

Cordially, Irvine Page One of the recurring features of much significance is the admiration which those in other dis;ciplines had for his clinical and investigative work. F'or example, the late Edward A. Park, regarded by som e as the most outstanding pediatrician thus far in tIiis century, wrote him several months after his arrival in Baltimore saying: Before starting in work tonight, I w rsh to state again my admiration at the moves you are for your Department. You will have so on aplaning unique Department of Surgery which will stanod above and set an example to all other Departmients in the country. I feel like giving three cheers that you are aswel thinking of surgeons in terms of physio as surgery. While in Baltimore, the Friday Noon Cllinics, which had been begun by Halsted, were always ,exceptional and attended by students, residents, and faculty alike (Fig. 6). On the investigative side, Dr. Blailock' s early work was a continuation of studies on shock, but shortly thereafter his major attention tuirned toward the heart. At that time, Dr. Taussig was Head of the Congenital Heart Disease Clinic in the Dexpartment of Pediatrics and was involved in the care of cyanotic and desperately ill children with the tetralo)gy of Fallot. She presented the problem of inadequate pulmonary blood flow in these patients and asked D Ir. Blalock if there might not be a way to increase this flo ,w by a surgical approach. He recalled that six years coarlier, in an effort to produce experimental pulmoinary hypertension, he had joined the systemic andI pulmonary circulations by direct anastomosis w ith marked augmentation of pulmonary blood flow ((Fig. 7). Although the laboratory experience had be en negative from point of view of producing pulmo ,nary hypertension, he nevertheless remembered the technique, and particularly the fact that in long-ten n follow-up there were no adverse changes to be fibund in the

thagyou

Ann. Surg.

9

September 1978

pulmonary microcirculation. In fact, the animals tolerated the subclavian artery to pulmonary artery anastomosis and without ill effect, amazingly he in 1939. Nevertheless, publishedwell work that was wished to be certain that the polycythemia and cyanosis, which occurred in patients with pulmonary stenosis and atresia, could be reversed by a systemic pulmonary shunt. For these studies, he developed a rather complex but appropriate experimental model by a combination of pulmonary resection and arteriovenous shunts in the remaining lung. Following these studies in the laboratory, he was convinced that a systemic pulmonary shunt would not only reduce the cyanosis but also decrease the high hematocrits in patients with tetralogy of Fallot. On November 29, 1944, he operated upon a severely cyanotic infant who had spent a prolonged period in oxygen and created the first pulmonary systemic shunt. Fortunately, the child obtained an excellent response, and the procedure was repeated shortly thereafter in several additional patients with equal success. Within a short period, a new and historic surgical procedure became established, and news of this rapidly spread throughout the nation and around the world. This work was published in The Journal of the American Medical Association (Fig. 8), and in a short time, patients were referred in large numbers from both this country and abroad. A new era had opened in the life of Alfred Blalock and for the entire field of cardiac surgery. In 1948, Dr. Blalock was invited to give the first Rudolph Matas Lecture at Tulane, which was on the topic of "Surgical Procedures Employed in Anatomical Variations Encountered in the Treatment of Congenital Pulmonic Stenosis." This paper was to become one of the most frequently quoted of all his publications and contained the beautiful illustrations ofthe anatomic variations and stepwise surgical procedures by the well known medical artist Leon Schlossberg (Fig. 9). Matas was very impressed with this lecture and was to wire Dr. Blalock: TIS MIDNIGHT AND ONLY ONE HOUR SINCE I HAVE MY FIRST GLIMPSE AT OCTOBER NUMBER SGO I COULD NOT FINISH READING YOUR MONUMENTAL NU SIGMA NU LECTURE WITHOUT RUSHING TO THE PHONE TO TELL YOU THAT MY PRIDE AND VANITY HAVE BEEN SO DEEPLY STIRRED BY YOUR DEDICATION AND MELODY OF YOUR PRAISE HAVE STARTED A FLUTTER IN MY HEARTSTRINGS THAT WILL KEEP ME FROM SLEEPING TONIGHT BUT I FORGIVE YOU CORDIALLY NONE THE LESS R MATAS

VOl. 188.9 NO. 3

PRESIDENTIAL ADDRESS

263

FIG. 9. Illustration from Alfred Blalock's Matas Lecture delivered at Tulane University entitled "Surgical Procedures Employed and Anatomical Variations Encountered in the Treatment of Congenital Pulmonic Stenosis," published in Surgery, Gynecology & Obstetrics, 87:385, 1948.

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THE SURGICAL TREATMENT OF MALFORMIATIONS OF THE HEART IN

WHIICII THERE IS PULMONARY OR PULMONARY ATRESIA

STENOSIS

ALFRED BLALOCK, M.D. AND

HELEN

B. TAUSSIG, M.D. BALTIMORE

Heretofore there lhas been ino satisfactory treatmiient pulmiionary steniosis an(l l)Ulmonaly atresia. A "bllue" baby xvitlh a miialformiied lheart was considered beyond the reaclh of surgical aid. During the past tlhree monitlhs we have operated oni 3 children witlh severe degrees of pulmonary steniosis anid each of the patients appears to be greatly beniefited. In the second and tlhird cases,

for

FIG. 8. Title page of first clinical report of the Blalock-Taussig operation published in the JAMA, 128:189, 1945. >

FIG. 11. The last public appearance of Alfred Blalock on the occasion of the celebration of the seventy-fifth anniversary of the Johns Hopkins Hospital. He is delivering the keynote address at the dinner on May 14, 1964.

10.

Photograph taken

at the home of

Professor

Philip

Allison

with Alfred Blalock and the author in May 1954. Professor Allison's cricket field lies behind in the distance. Nuffield Professor of Surgery at the

Shortly thereafter he became University of Oxford.

264

SABISTON

Today, the Blalock operation continues to be used, primarily in severely ill infants with tetralogy of Fallot, and one recently published paper stated that this operation was the procedure of choice in infants requiring an operation in the first year of life. There is also a very interesting episode which Dr. Blalock had with Yousuf Karsh, the noted Canadian portrait photographer. Karsh said: In 1950, as he was about to perform his thousandth blue baby operation, his colleagues commissioned me to commemorate the event, but the surgeon, I was told, 'would take a great deal of persuading.' As one of his associates explained to me, he could be enticed before my camera only with an innocent subterfuge. I was to tell him in the interest of his profession he must be included in my gallery of scientists. We spent a lively evening together. At dinner, by way of discovering his personality, I talked freely about doctors and remarked rather brashly that in the main they were very vain creatures. He took this in good part and suggested that, if I were interested in his profession, I had better see a blue baby operation for myself. Accordingly, I was amazed and not a little nervous to find myself in an operating room next morning wearing a mask and gown and standing at the left hand of the surgeon. Then for two hours he applied the magic of his mind and fingers to the body of a child seven years old. I was awed by Dr. Blalock's dexterity and more by his calm. He proceeded easily and naturally, often talked to me with no sign of tension, explained his methods to visiting doctors from many parts of the world who sat in the operating amphitheater. As time wore on I lost my awe and two hours stretched into eternity. Nothing disturbed Dr. Blalock. He finished his incredible task on schedule, ordered the patient wheeled out of the operating room, and removed his gloves like a man who had done an ordinary morning's work. But his single thought was for the mother of the child. Before he had even removed his gown, he went to telephone and assured this anxious woman that the operation was successful. His telephone conversion, more than his skill, told me what sort of man I was going to photograph. And I hastened to say to him, 'Dr. Blalock, I take back everything I said last night about the vanity of doctors. If you have such a thing, which I doubt, you are more than entitled to it.' Karsh was to subsequently publish an album of his portraits of the world's greats, and it is rather poignant that there are five physicians included in this album entitled Portraits of Greatness, Charles H. Best, Sir Alexander Fleming, Wilder Penfield, each of whom is a Nobel laureate, and, in addition, Jonas Salk and

Alfred Blalock.

Ann. Surg. * September 1978

In April 1945, Dr. Blalock was elected a member of the National Academy of Sciences, the highest scientific and academic honor. He received a large number of commendations from scientists throughout the country. Representative ones include that from Donald D. Van Slyke of the Rockefeller Institute who said, "It was a great pleasure to learn that the Academy had honored itself by electing you." And another from Vincent Du Vigneaud who said, "Just a little note to extend to you my most hearty congratulations on your election to the National Academy of Sciences. This recognition of you and your work is richly deserved." And from Charles Huggins:

Dear Al: I have just read in Sc ience the good news of your election to the National Academy of Sciences. The wisdom of the electors is apparent and has made us feel very happy. I wish to extend my very best congratulations to you on this well deserved recognition of your brilliant scientific accomplishments.

With his usual humility, Dr. Blalock replied: Dear Charlie: It was exceedingly thoughtful of you to write to me regarding my election to the National Academy of Sciences. It was a great surprise to me and I hope that those responsible have not made too bad a mistake. To Dr. Blalock came many national honors, including the Presidency of the American Association of Thoracic Surgery in 1951. In 1954, he was President Elect of the American College of Surgeons, and a number of the members of the College traveled jointly to Scotland, England, and France during April for combined meetings with surgical organizations in those countries. At Harrogate, near Leeds, the American College met jointly with the Association of Surgeons of Great Britain and Ireland. The author had the privilege of accompanying Dr. Blalock on that month's tour, and it was an extraordinary experience. While at Harrogate, Professor Allison was our host in his beautiful home in nearby Leeds, which had extensive gardens and a cricket field (Fig. 10). The close friendship which was to subsequently develop between Alfred Blalock and Philip Allison began during that week and continued throughout his life. In his Presidential Address to the College, Dr. Blalock showed a deep insight into current problems as well as the future. He stated: "Our system of medical education, undergraduate teaching, and residency training is in serious danger." He proceeded to emphasize that tuition had been greatly increased, but that still such fees accounted for only a small part of the actual cost of medical education, stating further:

"Worthwhile candidates who

simply cannot afford to

VOl. 188 . NO. 3

FIG. 12. Photograph of Alfred Blalock and his much admired Chief Resident William P. Longmire, Jr. This photograph is taken in the courtyard of the Johns Hopkins Hospital at approximately the time of the first BlalockTaussig procedure. Dr. Longmire was his first assistant on that historic occasion.

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FIG. 13. Photograph of Dr. Blalock with his Chief Residents.

FIG. 14. Dr. William H. Muller, Jr. presenting Dr. Blalock with a silver tray on which were engraved the signatures of all of his Chief Residents at Hopkins on the occasion of the last meeting with the Residents prior to Dr. Blalock's death. The meeting was held in the Department of Surgery at the University of Virginia at Charlottesville headed by Dr. Muller.

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266

SABISTON

go to medical school are eliminated from the profession." He further feared the fact that private endowments were not likely to increase significantly under the present tax structure and he hoped that more aid would be available "without strings" for medical schools in the future. It is striking to recognize the current significance of this farsighted address delivered more than 20 years ago. In 1956, when Alfred Blalock was President of the American Surgical Association and presented his address on the topic of "The Nature of Discovery," he stated: For many years I have been interested in the background or the nature of discoveries in medicine and this is the subject of my address. Discovery may be defined as the act of finding out what was unknown, such as Harvey's discovery of the circulation of the blood. One discovers what already exists but was unknown previously, such as the applicability of steam to the purposes of locomotion.... It must be admitted, however, that the distinction is often a close and debatable one. Whereas we usually give the name 'discovery' to the recognition of a new fact, Claude Bernard maintained that the idea is what really constitutes the discovery. He said, 'The idea is the seed; the method is the earth furnishing the conditions in which it may develop, flourish and give the best of the fruit according to its nature. But as only what has been sown in the ground will ever grow in it, so nothing will be developed by the experimental method except the ideas submitted to it.' What are the methods by which discoveries are made? We may distinguish roughly four general categories: (I) Some are made by chance or accident; (2) some are made by intention or design; (3) some are made by intuition or imagination or hunch; and (4) some are made by combinations of two or all of the above methods. The mode of discovery is not always clearcut. It has been my experience, and I am sure yours, that one cannot always recall exactly how one spotted the clue that allowed him to solve the problem. In this remarkable address, he reviewed accounts of the background of a number of major contributions in medicine. For example, he chose to cite Claude Bernard's maxim, which all of those who worked with him knew he fully endorsed: "When we meet a fact which contradicts a prevailing theory, we must accept the fact and abandon the theory, even when the theory is supported by great names and generally accepted." During these remarks, his abiding dedication to hard work was brought into focus when he said:

Ann.

Surg. * September 1978

I would place first among the requisites of an investigator the willingness and the desire to work. No amount of brilliance or good fortune relieves one of the necessity of hard work. Even the brilliant accidental observation has to pass rigorous tests before it is proved and accepted. ... No satisfaction is quite like that which accompanies productive investigation, particularly if it leads to better treatment of the sick. The important discoveries in medicine are generally simple and one is apt to wonder why they were not made earlier. I believe that they are made usually by a dedicated person who is willing to work and to cultivate his power of observation rather than by the so-called intellectual genius. Discoveries may be made by the individual worker as opposed to the current practice of a large team research. Simple apparatus may suffice; all the analyses need not be performed by technicians; large sums of money are not always necessary. Important basic ideas will probably continue to come from the individual. Whether by accident, design or hunch, the diligent investigator has a fair chance of making an important discovery. If he is unwilling to take this chance, he should avoid this type of work.

At the meeting of the American Surgical that year, Claude Welch, a very objective observer, wrote: My dear Al: The last meeting of the American Surgical was by all means the best that I have ever attended. This was true because you ran it absolutely magnificently. There was just the right touch of seriousness and informality all the way through. In 1960, Henry Bahnson, Mark Ravitch, Glenn Morrow, and the author arranged a dinner in his honor. On that occasion a large number of friends from around the world met in Baltimore to honor him. The Baltimore Sun made the event a special feature, stating in part: Medical men from various parts of the western hemisphere and Europe gathered at the Southern Hotel last night for a dinner honoring Dr. Alfred Blalock, Professor of Surgery at the Johns Hopkins Hospital. The guest list totaled nearly 500 persons and a number of those present were surgeons trained by the soft spoken, Georgia born Dr. Blalock. The dinner was arranged by a Hopkins group and preparations were made without the knowledge of the man being honored. The tributes that evening were superb and brought obvious joy to the Professor. The distinguished physiologist Philip Bard, who was for many years Professor and Director of the Department of Physi-

VOI. 188.9 NO. 3

PRESIDENTIAL ADDRESS

267

FIG. 15. Locations of Chief Residents of Dr. Blalock who held positions of Chairmen of Departments of Surgery or Chiefs of Divisons of Surgery.

ology at Hopkins and later Dean of the School of Medicine, said: I have known Al personally for 20 years. Before that I knew him through those of his published papers which every respectable physiologist interested in the cardiovascular system had to read To if he were to keep abreast of the subject. a physiologist, his studies were of the utmost importance. After World War I, physiologists lost all interest in somatic and other kinds of shock and the surgeons took over, led by Al. This was a classic, and the work during World War II confirmed it, and I merely want to state as a physiologist how indebted we are to him. .

Dr. Blalock's talents in administration scored by Philip Bard when he said:

were

.

under-

During my term of service as Dean of the Medical Faculty, administrative duties gave me an insight into the difficulties he had in directing a huge Department filled with personalities and individualities that cover a broad spectrum of human nature. During that period, I also felt the impact of his resourcefulness as the Head of the Department in obtaining what he deemed necessary for the Department and its staff, particularly the younger members. Philip Bard concluded his remarks by quoting from Samuel Crowe's biography, "Halsted of Johns Hopkins-The Man and His Men": "Halsted was the founder of a school, the disciples of which have perpetuated his influence and prestige as one of the

great creators of scientific surgery." Moreover, Crowe said, "The spirit of Halsted has been reincarnated in his successor, Alfred Blalock." Joseph Beard, who worked with Dr. Blalock in the experimental laboratory early in his career and was to become a virologist of worldwide renown, receiving both the Borden Award and the Clowes Cancer Award, said of Dr. Blalock that evening: -I don't know how well you all really know Dr. Blalock but you know as you look at him here he looks so calm, self-possessed, composed, kind, and all that sort of thing, but you never really did work for that fellow. The trouble with him, so far as I was concerned . . . a 24 hour day was just nothing at all. He would come in the laboratory and start about 7:30 or 8:00 in the morning and about 1:00 a.m. he'd leave me holding the sack until the next morning just before 7:30. . . . But this I can tell you, Dr. Blalock is a friend of enduring and lasting capacity. All through the years that I have known him he has never forgotten the fact that once upon a time I worked for him and he has never forgotten the obligation of a teacher to aid and to sympathize with the advance of one of his students. His coworker, Helen Taussig, said: "It is with the greatest of pleasure that I salute you tonight. . . . It was in 1942 that Dr. Blalock first proved to everyone at Hopkins that he was a great thoracic surgeon with our first successful ligation of a patent ductus arteriosus." Regarding the work on the tetralogy of Fallot, she said' "Al, the true scientist, took the problem to the laboratory where he performed the many tests to es-

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SABISTON

tablish the fact and to develop a technique which made the operation so successful." The Professor of Surgery at the University of Turin, A. Mario Dogliotti, cited the fact that the largest cardiovascular surgical center in Europe at that time was the Blalock Center at the University of Turin. He concluded saying, "From your lips and through your eyes tell the happiness of everybody who knows you, and loves you." The late Isidor Ravdin paid him a remarkable tribute when he said: "Alfred Blalock's work in shock was monumental in concept and in analysis. It was he who demonstrated firmly the effects of trauma and blood loss. Alfred Blalock represents the finest of the physiologically minded surgeons who followed after the death of Dr. Halsted." His close friend from Oxford, Philip Allison, said, "You, Alfred Blalock, by your continuing scholarship, integrity, and insatiable curiosity have grown to immense proportions for these men and many more throughout the world." Mark Ravitch, speaking for the residents, said: .

.

.

It didn't take us long to find out that what we had formerly thought was superb clinical performance, that is, working 24 hours a day was merely expected and accepted. It was really infuriating, but it was a fact of life. Even more work, more detailed attention to the students, to experimental work in the Hunterian Laboratory, in the Library, in the operating rooms, all became the order of the day for all of us after his arrival at Hopkins. .

.

.

His close friend and coinvestigator of many years, Tinsley Harrison, the distinguished Professor of Medicine and Editor of the well known Textbook of Medicine, said: A teacher is an individual who has the capacity to influence the horizons of his pupils. Al has had that capacity all of his life. And there is another part of the story, one to which many individuals can testify, and perhaps no one quite as much as I, having been his intimate friend for more than 40 years. The story is that none of us who have ever touched him have been left without the impact of a broader and better educational influence and a greater and stronger inspiration. .

.

.

.

.

.

His fellow classmate and long time friend, Arthur Blakemore, commented on his remarkable productivity and ended by proposing a toast to the more than 500 present when he said, "A toast to this man, the finest house officer Johns Hopkins ever had." At the table with him that evening was Alice, his second wife, who had been

a close

friend of Mary

Ann. Surg.

o

September 1978

Blalock before her death, and who brought him much happiness in the remaining years. It was apparent to all present at the dinner that Dr. Blalock had been deeply moved by the many tributes paid him, and in closing said:

With the exception of my family, and personal friends of my own vintage, many of whom are here tonight, my greatest pleasure in life has come from the house staff here, and at Vanderbilt. At Hopkins we have had 37 senior residents in the past 19 years. Most of them are here tonight, much to my delight. All of these 37 are successful. A number of them are known nationally and internationally. All are fine gentlemen and superb friends. At the dedication of the Brady Urological Institute some years ago, Diamond Jim Brady simply said, "The sky was never so blue and the grass was never so green as they are this day for me." These are my sentiments tonight, thanks to you. * His wide and continuing impact throughout his medical education is documented by Visiting Professorships in all the medical schools in the nation, the delivery of more than 40 named lectureships including the lectureships named in honor of Arthur Dean Bevan, Donald Balfour, Edward Churchill, DaCosta, Phemister, Lord Moynihan, and the Shattuck Lecture. He received many international honors including election into the Royal College of Surgeons of England and Edinburgh, the Edinburgh Royal Society of Medicine, the Society of Thoracic Surgeons of Great Britain and Ireland, the Association of Surgeons of Great Britain and Ireland, the British Cardiac Society, the Academie de Chirurgie of France, the Argentine, the Belgian, and Greek Societies of Surgery, the Royal Academy of Medicine of Belgium, and many more. One of the societies to which Dr. Blalock was elected was the American Philosophical Society, and he let it be known that inclusion in this distinguished and erudite group brought him much happiness. He wrote George Corner at that time saying, "I am thoroughly delighted and even more surprised in being elected to membership in the American Philosophical Society." A very selective and scholarly group, review of the membership at the time of his election reveals only three other surgeons on the roster-Charles Huggins, Wilder Penfield, and Jonathan Rhoads. In a reply to Dr. Ravdin who had written his congratulations, he said: career upon

* Dr. Blalock's closing remarks at the dinner were filmed with a sound track and done without his knowledge. The film was shown at this point during the address to the members of the American Surgical Association, and for the first time at a national meeting.

Vol. 188.o No. 3

PRESIDENTIAL ADDRESS

Dear Rav: Thank you for your nice note about the American Philosophical Society. Certainly I am in good company when I was elected at the same time that you were chosen. I suspect that Jonathan Rhoads played a part in this. At any rate, I am very pleased. There is little doubt among those who knew him well that his last public appearance and the address that evening provided his listeners with an insight into his philosophy and into the deepest recesses of his mind. He had been invited to deliver the keynote address of the seventy-fifth anniversary of the opening of the Johns Hopkins Hospital on May 14, 1964, this being only a few months before his death. Although at the time his diagnosis was not known, and there was little reason to suspect what was to happen shortly thereafter, nevertheless the author and many others had a sense of the impending event and indeed that he himself was aware of it. He had recently undergone a fusion of the lumbar spine for what was thought to have been a herniated vertebral disc but was later proven to be metastatic carcinoma to the vertebrae. He had lost considerable weight, was in continuous pain, and was deeply worried about a group of recent administrative problems and decisions at Hopkins. Despite this combination of concerns, his tenacity and loyalty to the institution made him determined to deliver the address to which he had previously committed himself. A special chair and support system were placed behind the lectern, and he then began the most poignant and certainly the most deeply felt address of his entire life (Fig. 11). His opening remarks had a touch of humor, probably included more than anything else to help place the audience at ease, since all were aware of his recent operation and continuing pain. He greeted the mayor of the city, who was in attendance that evening, and who had also recently been a patient at Hopkins for treatment of asthma. Dr. Blalock began his remarks by saying "Unlike Mayor McKeldin, I fell into the hands of surgeons, and I hope the next time I am in the hospital I will have asthma. ' From that point, he then reflected upon the proceedings of the twenty-fifth anniversary of the Hospital, and of that era he quoted Osler who said: And binding us all together there came as a sweet influence a spirit of the place; whence we knew not but teacher and taught alike felt the presence and subtle domination. Comradeship, sympathy one with another, devotion to work were its fruits and its guidance drove from each heart hatred and malice and all uncharitableness.

He further reminded those present that evening of the fiftieth anniversary when Winford H. Smith, the long time Director of the Hospital, had said, "That

269

'spirit of the place' referred to by Osler. Its effect the life of the hospital and in molding the character of the individuals brought under its influence make it something priceless." At this point, he began a review of the many problems which then faced the Medical School and the Hospital. In fact, a number of these same problems continue in some of our institutions today. I think it is useful for all of us, and for many reasons, to emphasize the practical advice and admonitions he stressed at that time. He said: .

.

.

upon

Quality is more important than quantity, and too great a size may mean unwieldiness. Next, excellent

patient care and teaching and clinical research should be accorded a status of dignity equal to that of the so-called laboratory research. He further emphasized: "The full time members of the hospital staff should consist, with few exceptions, of clinicians who have great interest in patient care and teaching." He concluded that while he admired tradition greatly he recognized that it should serve only as a stimulus and not as a wall behind which to retreat. These were his last public remarks. During the next several months, as his physical condition rapidly weakened and he was in constant pain with multiple bony metastases, the author had the privilege of sitting with him for many hours. His primary pleasures at that time were reminiscences about his residents and reflections upon his, and their, earlier work. He was especially close to Bill Longmire and spoke of his good fortune in having him as first assistant during the first tetralogy operation in 1944 (Fig. 12). He recalled the work with Rollins Hanlon in developing the Blalock-Hanlon operation during many hours in the Hunterian Laboratory. He was also pleased that H. William Scott had succeeded his former Chief, Dr. Barney Brooks, particularly in that happy and productive environment he recalled so clearly. He spoke of the visit he and Henry Bahnson made to England and France in 1947 where they introduced the Blalock operation in Europe, and of which Evarts Graham was to say in a letter to President Bowman: Dear Mr. Bowman: I wish you could have been with me in London last month to have seen the acclaim which Alfred Blalock received. It did my heart good to see it. I could not help recalling some of the correspondence and conversations which you and I had about him a few years ago when he was being considered for his present post. I have always been sure of his ability and I have always been confident that he would go far in surgery if he had a good opportunity. I was

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tremendously proud of him in Europe, and I could not help getting a great deal of satisfaction out of the thought that my confidence had not been misplaced. There has never been anything quite like Al Blalock's triumphal tour of Europe. The only thing that I can think of that remotely resembles it was a tour made by Marion Sims in the seventies or eighties of the last century. He had devised an operation and was received with great acclaim in the European capitals because of the success of his demonstrations. He came back loaded with honors from the various crowned heads. Al Blalock's tour has been no less dramatic and successful despite the fact that Europe is now down at the heel and there are few crowned heads left. The prestige of Johns Hopkins was enormously increased by Al's visit. All of us Americans were proud to claim him as a fellow American. His unassuming personality captivated everyone as much as his epoch-making surgical accomplishment. Another of those with whom he was particularly close was William H. Muller, Jr. The last meeting of the Blalock Residents was held at his Department at the University of Virginia in March, 1964 (Fig. 13), and at that time Dr. Blalock was presented a silver tray upon which were the engraved signatures of the Hopkins Residents whom he had trained (Fig. 14). Dr. Blalock's influence in creating clinical surgeons, teachers, investigators, and Department Chairmen had been similar to that of Halsted, and as he reviewed it all in perspective, he was warmly grateful that he had had such an opportunity. Longmire headed the Department at the University of California at Los Angeles, Hanlon at St. Louis University, Scott at Vanderbilt, Muller at the University of Virginia, Bahnson at Pittsburgh, and the author at Duke. Others were chiefs of Divisions, including Sloan at the University of Michigan, Pickrell at Duke, Morrow at the National Heart Institute, Cooley at Baylor, Maloney at the University of California at Los Angeles, Haller at Hopkins, Hatcher at Emory, Weldon at Washington University, Kay at the University of Southern California, and Jude at the University of Miami. Subsequently, Rainey Williams was to succeed in the chair at the University of Oklahoma, Lazar Greenfield at the Medical College of Virginia, and Paul Ebert at Cornell and later at the University of California at San Francisco (Fig. 15). Among the remainder of the Residents, six were in the private practice of surgery and 17 held academic appointments. A special cabinet was presented to him for appropriate placement of his many medals and honors including the Passano Award, the Rene Leriche Award, the AMA Distinguished Service Award, the Lasker

Ann. Surg. m September 1978

Award, the Roswell Park Medal, the Gairdner Award, the Bigelow Medal, and the Chevalier de la Republique Francaise Nationale de la Legion de Honneur. As the remaining days passed, he recalled each resident with much fondness and warm reflection. As Mark Ravitch was to write later in his Collected Works of Alfred Blalock: "'His intermittent stupor mercifully lightened two days before his death when one 'by one his old residents-Longmire, Scott, Hanlon, Muller, Bahnson, Sabiston-now away in chairs of their own, came in to see him." These last visits made deep impressions upon us for, despite his illness and pain, he continued to maintain his gracious attitude, his appreciation, and his loyalty to all of us. As the candle grew dim, and when on September 15 the final day came, all knew that his life had been fully complete, touching a vast number of grateful patients, many admiring students, a group of loyal residents, and a host of warm friends everywhere. His productive life, characterized as it was by many original ideas and achievements, fulfilled in all dimensions the criteria of the noted medical historian, Henry E. Sigerist, when he said: Posterity weaves garlands for those alone whose work has been creative. No doctors live on in the memory save the exceptional beings who enriched the healing art with new outlooks, who forged new weapons for the fight against disease, whose activities were vital to the development of medicine, to those who incorporated a trend, founded a school or represented an era. We remember those choice spirits who, becoming aware of divine thoughts that were still inchoate, were able, by strenuous labor, to make them generally known and practically applicable. It is only of such great doctors that I can write. Finally, the statement of Henry Brooks Adams penetrates directly to the mark when he said, "'A teacher affects eternity, he can never tell where his influence stops"-surely, this can be said of Alfred Blalock today. In concluding, let me thank you again for the privilege of sharing these thoughts with you. This honor, this day, and this hour will be a fond remembrance for me and for my family here this morning far into the future. Please accept my enduring gratitude. Acknowledgment Appreciation is expressed to Dr. William P. Longmire, Jr. for permission to reproduce Figures 12, 13, and 14 from his Alfred Blalock-Personal Reflections. The author is also indebted to Frances Grebel, Dr. Blalock's long-time secretary beginning with the Vanderbilt days, for whose extraordinary abilities he had the highest regard.